Oxfam France • 104 rue Oberkampf, 75011 Paris • 01 56 98 24 40 • [email protected] • www.oxfamfrance.org
Social Health Protection in Low Income Countries
Building up from the evidence
Marame NDOUR AfGH Seminar on UHC – Madrid - 25 October 2012
Social Health Protection in LICS : a global social challenge
Huge inequalities in access to health services which reflect inequalities in wealth & power
HC spending inversely proportional to global burden of disease
80’s : healthcare reform in LICs politically driven by influential institutions (WB, Usaid, OECD…), pro-market approach influencing research & policy making
2000’: UHC push by WHO “the single most important concept in public health today” : new Alma Ata?
Exit from a market style blueprint for healthcare protection in LICs ?
Previous assumptions: LICs lack the tax base to develop publicly funded healthcare
Solution : out of pocket spending/user fees• inefficient in HSS ; failed to increase revenue• failed to adress inequalities in access to health care
Recent paradigm shift and attempts to reshape healthcare systems to widen access• Abolish user fees , subsidize free healthcare initiatives • Risk pooling social health insurance…
The situation in LICs
« Inverse care law » : those most subject to ill-health are least able to pay for it
Low levels state and private HC spending
High level of diseases of poverty, preventable mortality // beginning of an epidemiological transition (NCDs burden)
Poor infrastructure of 1ary & 2ndary HC; shortages of skilled health staff; high cost of modern medicines and medical equipment
Inequalities in access : rich/poor; rural/urban; preferential access for the elite and formal sector
Lack of local and democratic control over health policies
What doesn’t work?
Charging even small user fees: financial barrier, complex, costly, inefficient
Two-tier systems with services targeting the poorest & general attempts to target and exempt poor people in LICs • difficulty to identify those qualified • inclusion/exclusion problems
Private health insurance: still no evidence that it can benefit more than a limited group of people
Profit driven private actors involved in delivery of services intended to benefit poor people• Private sector of its own can nowhere deliver a comprehensive health care
system• Needs to be combined to public subsidy and provision for most demanding &
unprofitable cases
Oxfam 2006, In the public interest
What does work for the most vulnerable?
Universal, free or extremely low priced services are more effective to achieve equity & widen access
2% of GDP Govt spending on a UHC system would allow to reduce or eliminate user fees with a huge benefit for the poorest (2005 Equitap research health equity in Asia)
Well organized, upgraded and adequately funded universal public services
Supportive actions to ensure most vulnerable have access to & use these services
NEPAL26.6 million83% of the population live on less than US$2/day
Enormous health challenges, wide inequalities, e.g in maternal and child care• 1 in 80 women will die in pregnancy or childbirth• Skilled birth attendance: richest 20% of women benefit 12 times
more than the poorest 20%; • 1 in 19 children will die before their fifth birthday: twice likely to
affect children in rural areas
Strong political will for UHC backed by donors - Right to health enshrined in 2007 constitution - Move from 7% to 10% of national budget on health
Key Social Security Programmes
Maternal health programmes• Safe Delivery Incentive” in 2005• transport; user fees abolition in 25 poorest districts; financial
incentive for health workers attending deliveries• “Aama”in 2009• free hospital deliveries, antenatal & post natal & family
planning services for all women in public health facilities
Free essential health care services • 2008 : user fees removal in public health facilities throughout
Nepal (for PHC; free essential medicine, targeted free 2ndary care for senior, disabled, minorities...)
Positive impact
General increase in utilization of healthcare• outpatient care doubled• inpatient care increase by 6-10 folds in 2 years of user fees removal
< 50% increase : number of women giving birth in health facilities • remarkable increase : 6% to 20% in most poor districts• significant reductions in the cost of care for women
Improved equity in access to services• the poor, senior citizens, women and marginalized people are
benefiting more than other groups
Nepal Free healthcare initiatives challenges
Low awareness about the free healthcare initiative
Low funding in 2010/11 • government spending around 7%• per capita health gvt allocation US$7.60 (far lower than the
WHO recommended US$60)
Health systems shortfalls • Inadequate health infrastructure; poor referral system,
Inadequate human resources (trained health workers shortages go abroad/private), 1:30 000 doctor ratio
Gvt plans: introduce mandatory health insurance
Pilote scheme in selected districts in 2012 nationwide in 5 years
Mandatory enrolment + premium Extension of covered health services
Concerns: risk of scraping the free healthcare policies, high premiums, inefficient exemptions for targeted groups
Evidence from Ghana and Tanzania shows that health insurance is often inefficient and exclude the poorest and most vulnerable
Evidence from African countries
RWANDA : 60% of population live with less than 1$/day
Mutual health insurance schemes• Pilot scale in 1999• Rural/informal sector coverage• 2$ (enrollment + 10% co-payment of cost of services)• Laws enforcement requiring Mutuelle enrollment• Scale up to more than 91% coverage in 2010 where most
community insurance are far below 10% of coverage
Cited questionably as an example of how community health insurance can scale up to achieve large coverage
Rwanda achievements … can not be only attributed to Mutuelles !
Insurance coverage• 2003 to 2010 : 7% to 91%
Services utilization• 0.31 to 0.95 outpatient visits per capita
Under 5 mortality decreased• 2005 to 2010 : 12,5% to 7,6% (similar to South Africa, India)
Secret n°1 massive increase in gvt health spending• 2002 to 2010 : 10US$ to 48US$ per capita on health
• 2006 : of all health spending 53% from donors, 28% private, (of which 5% Mutuelles), 19% public
N°2: Improved service delivery + subsidization
Upgraded comprehensive service delivery • Increased health personnel; Reinforced drug supply• New equipment and general infrastructure improvement• Improved management (strong leadership and political will,
effective implementation…)
Combined to financial barrier reduction through subsidization • Utilization rates doubled/tripled only after (2$)/year Mutuelles
enrollment were subsidized & premium removed • 37% of enrolled households sponsored by government• 2011 study shows the impact of co-payment supression on
utilization of PHC facility in Mayange district
Annualized utilization rates for Mayange and 2 neighbouring health centres Jan-2005 to September 2007 (Dhillon & al, 2011)
Gvt plan to raise premiums WHILE co-payments remain an important barrier to access !
Co-payment: minimal contribution to local healthcare financing while costly to levy & manage
Upgraded services alone did not generate a dramatic increase in utilization + combination with fees removal
Point-of-service payments discriminate against the poor disproportionate use of healthcare by the wealthy Lack of money = barrier to healthcare among 83% of the lowest wealth
quintile // 52% in highest wealth quintile (2005) Other economic costs : geographic barrier; opportunity costs for
farmers…
“Higher coverage rates, often used to measure the success of insurance programmes are not sufficient
to improve access (ILO, 2002)
Current cost of subsidising all mutuelle premiums and co-payment = 25 million US$
Total cost of absorbing co-payments + complete subsidization of Mutuelle = 75 million US$
Challenges : expand access without aid dependance
Possibilities : • move to a centrally financed care free to the population (donor support)• Middle ground: target lower utilization, provide timely access for the poor ?• Examine ways of eliminating co-payments, increasing subisides for enrollment ,
expanding free services including curative care and free primary care to priority populations (children, pregnant women…)
DIRECT PAYMENT EXEMPTION POLICIESA critical component in promoting universal access
to social health protection ?
Gradually became prominent in a large number of low income countries
First dedicated to increase success of HIB/TB patients with international funding
Lately focus on maternal and child mortality & morbidity, PHC, elderly...
Requirements : precise planification, broad quality services coverage, adequate and sustainable funding
Potentially play a role in providing social health protection for the most vulnerable
Coverage for indigent & priority population
Free coverage for women/Children under five• Geographic SENEGAL: delivery care costs totally subsidized
everywhere except in the capital Dakar
• Services NIGER: free contraceptive services, antenatal care, deliveries, c-sections, breast & uterus cancers treatment ; consultations, surgery, medicines, and laboratory tests for children under 5
100% subsidization (except co-payments Burkina/Kenya)
Access in public and private facilities • Niger, Senegal, Sierra Leone : childbirth free only on public hospitals• Benin, Burkina, Burundi : also in private not for profit health centres• Kenya: private for profit and private not for profit sector
Sustainability challenges of these policies
Difficulties in implementation: lack of planification, acute funding shortfalls (unpaid healthcare bills, lack of external aid support predictability if any)
Targeting uneasy: complex definition of “poor” beneficiaries
People uninformed of their rights
Risk of non-compliance with free policies, informal fees
Complexity to articulate different co-existing free policies
Scaling up and transition to UHC?
Positive impactsEvidence from West African Countries
(report to be published early 2013)
On population • promote access to essential care, remove financial barriers• empower populations • benefit all, including the disadvantaged
On health services• opportunity to improve the quality of care (prescription, rational use)
and improve health services efficiency• reinforce resources and strengthen community participation
If well prepared and funded remain a realistic intermediary option for West-African countries striving to achieve UHC• Strong political will needed + accountability to populations• What about the Abuja promises?
Oxfam France • 104 rue Oberkampf, 75011 Paris • 01 56 98 24 40 • [email protected] • www.oxfamfrance.org
Many thanks for your attention !
Marame NDOUR [email protected]
